Sharing good practice—made easier
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d6350 (Published 12 October 2011) Cite this as: BMJ 2011;343:d6350
- Yasmin Ahmed-Little, specialty registrar, public health, North Western Deanery, UK,
- Nikita Kanani, GP registrar, London, UK,
- Toby Hillman, respiratory registrar, Royal Free Hospital, London, UK,
- Rob Bethune, surgical registrar, Severn Deanery, Bristol, UK,
- Benjamin Brown, primary care academic clinical fellow, University of Manchester, Manchester, UK
- thenetwork.org.uk{at}gmail.com
Abstract
Yasmin Ahmed-Little and colleagues of the online medical community The Network (www.forum.the-network.org.uk) explain their online casebook
Often you are halfway through the various trials and tribulations of a project, when someone helpfully says, “But Dr X tried this last year at trust Y; it might be worth speaking to her.” Why is it so hard to share our experiences across the single organisation of the NHS? Should we be looking at ways to stop people wasting precious NHS time reinventing the wheel or, rather, “reinventing the flat tyre”?1
Why don’t we share?
Clearly the sprawling nature of the NHS poses logistic challenges in effective communication. At a trust level, there are also concerns about letting another trust know what we’ve being doing well (or indeed poorly) and a reluctance to know what else is happening out there because “we are different at our trust” and “that is all very well but it wouldn’t work here.”
For doctors, however, some of the reasons behind our lack of sharing are perhaps a little different. Experience suggests that many of the day to day projects we are involved in simply do not occur to us as something worth sharing. The simplest projects are often the best, but they can be overlooked by people who think that they are just basic common sense and that others wouldn’t be interested. All too often doctors work in isolation on the most amazing pieces of work that no one else will ever see.
To complicate this further is the culture of the medical world and the importance it places on peer reviewed publications. Anything less than this can seem futile, barely making a dent on a CV and giving no academic kudos—and therefore hardly worth the effort.
Why should we share?
Good research governance encourages all research and the outcomes of research to find a way to reach the relevant audience, in particular to avoid the new wheels and flat tyres scenario and to avoid wasting increasingly scarce resources.
We also know that the medical profession is doing a lot and has a lot to share. At the launch of The Network in January 2011 a request for poster presentations of work that Network members had been involved in generated more than 20 submissions in the space of just a few weeks. And when we asked for examples of quality improvement projects another 20 or more ideas were submitted within days, covering topics such as weekend handover and discharge planning. A selection of these can be seen in the latest edition of Junior Dr magazine.2 People are doing a lot and are keen to share, if it is easy to do so and they have a supportive environment. And their projects are real and relevant, making them of great interest to others. The days of needing to get an audit done just as a tick box exercise to pass your annual review of competence progression (ARCP) are fast disappearing.34
What can we do?
The Network is a free online community that connects doctors, medical students, and other healthcare professionals so that the quality of care in the United Kingdom and elsewhere can be improved. We were keen to build on the momentum we had seen developing in this area and use our resources to make it easier to share and start a dialogue across the NHS. So we have recently launched our new website and created a new “projects” section (www.forum.the-network.org.uk/index.php?/page/projects) to house the Network Value Improvement Casebook series—an online casebook collection of precisely those projects we never hear about elsewhere.
With a membership of more than 1300 and growing, The Network would like to help collect frontline examples of how junior clinicians are making considerable changes for the better across the NHS on a daily basis. Junior clinicians at the front line have a unique opportunity to observe at first hand the types of improvements that are needed to improve the NHS—in terms of efficiency and effectiveness but also, crucially, for better care of patients. But junior doctors get little encouragement to share their work and often just quietly get on with it. The arduous process of peer review publication can act as a barrier to sharing good practice across the NHS. Our launch event showed that junior clinicians are active and have plenty of good practice to share when given a supportive environment.
On our website’s projects section Network members are able to upload details of schemes they are working on together with any associated relevant documents. Uploading takes only a few minutes, and we hope that this facility will help people share their experiences right across the NHS. The Network’s monthly newsletter will be used to highlight new projects that have been added to the site (www.the-network.org.uk/The_Network_Newsletter.html). With the support of the Department of Health’s quality, innovation, productivity and prevention (QIPP) right care team, we also hope to publish a selection of projects as part of the Right Care Casebook Series—a hard copy publication later this year—so we’d love to hear all about your experiences.
How do I share my project with others?
The site is very easy to use. Firstly select from the different categories through which to upload your project:
Quality improvement
Service redesign
Patient safety, or
Education and training.
If you believe that your project falls under a different category, let us know (thenetwork.org.uk{at}gmail.com) and we will see how it can best be accommodated.
Next add some details about your project:
Project title
What was the problem?
What changes did you make?
How did you demonstrate any differences you made?
What are your conclusions?
What lessons have you learnt that could help others?
Then, if you do have any associated documents that you think others would find helpful and that you are able to share, attach them to your project.
Finally, click the publish button, and there you have it: the start of a collection of case reports and experiences from which we can all benefit.
Casebook examples
If you do need more persuasion, the boxes give a couple of examples of the sorts of projects already live and active on the site.
Network Value Improvement Casebook—example 1
Category
Patient safety
Project title
Chest drain removal: current practice at our institution (by J Hyer, N Watson, C Orton, R Karthigan, and S Paramothayan)
What was the problem?
We identified a widespread lack of awareness of chest drain removal guidelines among doctors and nurses in our district general hospital after a questionnaire audit that was based on British Thoracic Society guidance. We believed that patients could be exposed to clinical risk, as complications from an incorrect technique can result in increased hospital stay, patient morbidity, and, rarely, mortality.
What changes did you make?
Junior doctors were given manikin based teaching on chest drain removal by a respiratory consultant. Our audit findings were presented at hospital and medical department audit days to help raise awareness. Results were also presented at a national conference.
How did you demonstrate any differences you made?
A re-audit was conducted nine months later using the same self reported questionnaire. The results of this re-audit are to be presented locally to maintain the momentum of this patient safety initiative.
What are your conclusions?
Most respondents were still unaware of the exact guidelines after interventions, but there was a significant improvement in the understanding of certain stages of the chest drain removal procedure. Regular teaching to educate new cohorts of doctors and nurses is needed. A chest drain removal protocol could improve adherence to guidance.
What lessons have you learnt that could help others?
We identified a clinical area where we believed patients to be exposed to avoidable risk and set out to identify the scale of the problem and develop a solution. Collecting data to support interventions is important and need not be complicated. Re-audit is essential to evaluate how successful interventions have been. Also, audit departments can be extremely helpful and are often underused.
Network Value Improvement Casebook—example 2
Category
Quality improvement
Project title
Unnecessary blood testing (by A Bhuva)
What was the problem?
Fast track protocols are now well established for elective surgery, and early discharge is becoming the vogue. This obviates the need for additional blood tests (C reactive protein and coagulation screens) in the early postoperative period as “screening” tools in place of bedside assessment. These are requested frequently and unnecessarily, however, imposing an extra burden on busy pathology labs and at considerable cost.
What changes did you make?
An intervention was designed with pathology and information technology (IT) personnel and with consultant approval. We introduced a notification on the computerised blood requesting system to remind surgical house officers of test indication and to make recent results quickly accessible before request of serial tests. We also provided education for junior doctors.
How did you demonstrate any differences you made?
We collected a prospective database of 114 patients under surgical specialties over two months and performed audit, intervention, and closure of the cycle. We demonstrated a 54% and 56% reduction in requests for C reactive protein and coagulation screens, respectively. This did not affect safety: average length of stay did not differ significantly (3.7 and 3.6 days, respectively), and the rate of complicated recoveries was 10.5% in both groups.
What are your conclusions?
Hospital costs are £5.37 for each C reactive protein screen and £8.34 for a coagulation panel. Based on 57 patients a month, this suggests that considerable savings a year could be made (about £36 000). The intervention improved accuracy of detection of complications by reliance on clinical examination and reduced the burden on pathology labs. Considerable cost savings were achieved through a frontline intervention without compromising patient care.
What lessons have you learnt that could help others?
Established practice can be changed through a simple intervention that achieved notable improvement, and IT is an effective instrument to realise such a change.